A Dutch scientist so beautifully put the simple truth that science is what scientists do in his own language thus: “Watenchap is wot watenchoppers doen”. The hypothesis in science should be refutable to be accepted as scientific. “Moon’s surface is made up of butter” is an excellent scientific hypothesis because it could be refuted by experimental methods after analyzing the material brought by men on the moon. The hypothesis that “faith heals” is very unscientific, as it can not be refuted! This is the essence of science. There is a very rigid wall around this establishment and anyone who does not agree is branded as not having the right kind of scientific temper. “Sciences do not explain; they only make models-mostly mathematical constructs-that, with verbal explanations, are said to work wonders” wrote a scientist, von Neuman.



One could build a bridge, fly an aircraft, or make a refrigerator using the Newton’s Laws of deterministic predictability, but when it comes to predicting accurately the weather for the next one hour or even the next twenty-four hours, science does not go right most of the time. There could be what scientists call the “butterfly effect.” (Edward Lorenz’s idea) However, one could always predict long term weather rather roughly. An example would be that one could predict that the monsoon in 2001 for India would be adequate, but one would not be able to say as to when it rains, how much and where!



Scientists never make mistakes, they think; their laws could only be found wanting under changed circumstances. They can never be faulted, though. Newton’s Laws were found wanting in the light of Einstein’s theory of relativity. Einstein could not stomach quantum concepts for quite some time! Although no scientist worth his salt has seen an electron or a lepto-quark, he could use them in his experiments! But if a man in despair feels God but can not see Him (why not Her?), we call him superstitious. “God exists” is as unscientific a hypothesis as “God does not exist”. Both can not be refuted experimentally.



In my concept the really great scientist was Werner Heisenberg, who for the first time, in his Uncertainty Principle, propagated the theory that uncertainty is the only certainty in this dynamic universe. Uncertainty, with many imponderables, is the whole truth and nothing but the truth in medical science. Heisenberg also thought that the best laboratory for science is that which is in between our ear lobes, the brain. The Indian concept that it is the human mind that could conceive things which, at times, can not be perceived by the senses, was reinforced by another great brain in physics, Ervine Schrodinger, in his Cat Hypothesis.



On the contrary, research, even medical research, has produced a deluge of information that is impossible to assimilate: most of it being irrelevant to patient care! It is estimated that there are around 34,000 new references being added to the Medline every month from about 4000 journals, the total number of the latter is around 100,000 now1. Stephen Lock, the former editor of the British Medical Journal, has estimated that only 1% of medical publications represent “good science”. That should be an eye opener to all of us 2.



This does not take into consideration the deliberate attempts to twist facts in publications to suit the drug or technology lobbies. A few glaring instances are not out of place here. The first “diet-Heart” study in Framingham, using nearly $110 million taxpayers' money, never saw the light of the day in print. This was because at the end of five years of study, when the negative results came to light, there already in place was a million-dollar industry of “health foods” booming. Publication of the study result would have been a deathblow to the industry!



An audit of thousands of coronary bypass surgeries showed that a large majority of the recipients of the bypass did not get any benefit, but the study conclusion distributed the benefit to a few, equitably among all the recipients!3 Recent analysis of the long-term benefits of Insulin and sulphanylureas in lowering blood sugar, especially in those without any symptoms, did not suit the convenience of drug manufacturers. The whole conclusion was twisted to show remarkable benefit universally4. Editorials in the leading medical journals like “Looking the gift horse in the mouth”, “Drug companies run medical education in the USA” 5, “Doctors going on strike might improve the health of the society” 6 and “Is Academic Medicine for sale?” 7 go to show the levels to which medical research has sunk. It is difficult to expect anything else in the monetary economy based on Darwin’s Law of the survival of the fittest!



Epistemology is that branch of philosophy, which deals with knowledge, trying to answer certain basic questions like what and how we get to know anything. A great medical scientist, Charles Sherrington, wrote in the year 1899: “Positive sciences can not answer the question “why”. They can, at best, answer “how or how much”. “A physiologist could say how does the heart contract, but will not be able to say why does the heart contract?” Since the time of Plato rationalists, lead by Plato and Descartes, taught that knowledge is intrinsic to ideas of reason, solely within the mind. Empiricists, on the other hand, argued that knowledge is derived mainly from sense experience. Medical science in particular depends to a great extent on empirical bedside experience that can not be put into any straightjacket rules to be generalized.



A leading American Surgeon, Miles Little, in his beautiful book Humane Medicine, examines what doctors do, what their patients expect from them, and how the expectations of both are not being met!8 Let us look at the epistemology of science in medicine. While all the studies in clinical medicine deal with cohorts of patients compared with normal population, in reality the doctor and his patient have only one to one relationships.



While n=infinity in medical scientific studies; n=1 in patient care.



Miles Little puts it so tellingly in this example. While a patient with Dukes B cancer asks the surgeon, before his operation, as to what would be his chance of survival after surgery, the answer should truthfully depend only on guessing! The scientific studies have shown that a person with Dukes B cancer has a 34% chance of being free from disease five years from the day of operation, but the treating surgeon would not have a clue as to which group this particular patient would fall into. The surgeon's answer to the patient is like the magician trying to pick a red pebble from a bag containing 34 red and 66 black pebbles! But the media keeps selling the idea to our patients that science is perfect. This could invite litigation when things go the way they do in patient care! This applies to all situations in medicine.



While it is true, as argued above, that the statement that 'faith cures' is unscientific, studies done in American hospitals, (not in India) have shown that prayer, that too intercessory prayer, (praying for others) reduces coronary care course scores significantly. The study concluded that prayer is a useful adjunct to standard therapy after a heart attack!9 There is something more than what meets the eye in the affairs of this world and I wonder if science, in its present avatar, could unravel all that! Even Albert Einstein exclaimed at one stage that "this world is not only a wonder, but a wonderful wonder."



In medicine, especially in the field of epidemiology, there is something of a gold rush going on, thanks to the informed public’s neurosis about health. In fact, "it looks like a strategic fearmongering!" There seems to be a kind of psycho-sclerosis (hardening of thinking akin to atherosclerosis, the hardening of blood vessels) in the minds of students and teachers of medicine about the risk factor theories. Most of us refuse to believe that the so-called risk factor hypothesis is definitely not the be-all-and-end-all of illness and death. Epidemiologists could, at times, cause an epidemic!



Epidemiology is very convincing to the lay public and it gives juicy and exciting news material for the media. Not a day passes without some new risk being found either as the cause of one or other disease, or as a panacea. Risk factor hypothesis is nothing "more than a shaky alibi"; it is respected because it has a rich business around for all concerned, especially the vested drug and technology industries. Most long-term human studies have given negative results in trying to assess the long-term benefits of risk factor modification but, we still try and sell the idea to the gullible public 10.



In his book Science without Sense, Steven Milloy, a respected epidemiologist himself, has this to say about the risk factor hypothesis. "Consider Alchemy, the forerunner of modern chemistry-even meta-analysis. It lasted until the Middle Ages having appeared back in the 5th century BC. It didn't fall into disrepute until some alchemists became obsessed with the quest for the secrets of transmutation and adopted deceptive methods of experimentation. Hmmm…you don't think…nah, it'll take forever for the public to figure out the shady type of risk assessment." I do not want to interpret this for you but leave it to you to come to your own conclusion.



Although there are many loopholes in the Darwin's theory of evolution, there is a concerted effort to sell the same as the last word in science by an establishment called the department of science communication in a prestigious University.11 Why do we have to sell science? The simple rule is that anything that is advertised normally has a very shaky foundation! This much for the establishment. The Darwin’s theory of the “survival of the fittest” is probably the reason why the so-called scientific temper has developed the killer instinct in every walk of life; everywhere man wants to eat man. The real theory should be the “Fall of the Fittest”. Look at any of the historical events-the fall of the mighty British Empire, fall of Hitler, the great, disintegration of the Russian Union, and many more. The ancient Indian theory of the “fall of the fittest” makes man altruistic. Even management gurus, like Subhash Sharma Ph.D, feel those management strategies using the "fall of the fittest" concept would work wonders12. This latter theory does not look at humans as resources but as creators. They could learn to live and let live.



One small information might not be out of place here. Newton’s apple story makes us excited as he gave the natural phenomenon a mathematical formula. Science is creating mathematical formulae anyway! Brahmagupta, many years earlier, wrote: “…it is the nature of earth to attract and keep things just as it is nature of water to flow, that of fire to burn, and that of wind to set in motion…seeds always return to the earth whatever direction you may throw them away and never rise upwards from earth.” (India by Al Biruni). 12 Quantum physics comes very close to Indian mysticism. Shankara’s rope and Schrodinger’s cat are almost identical.



Scientific activities keep humanity sane and take us away from illogicalism. But total reliance on science alone, without a touch of humanism, would certainly sink man into the valley of immoral "hate one another" psyche. We need a judicious mix of science and humanism. Physicians of yore were all men of wisdom and maturity.



Wisdom = reason + intuition (Sharma)



A wise clinician should, therefore, be rational, analytical and also intuitive and creative at the same time; medicine being basically an art based on scientific principles. Pure western science trained physician could make a good technician, but a wise physician would be a good healer. There is an urgent need for a paradigm shift in our thinking in this area lest we should fall back into the dark ages again! Science for science sake without a good dose of humanism is dangerous. Science of the conventional variety is slowly dying a natural death because of specialism. A new science of holism is rising in the distant horizon, where all the specialists should also be good generalists, to understand one another for the common good of humanity at large.



We should also see that technological advances do not take modern medicine farther away from the recipient. As of now nearly 80% of the world’s population does not have (can not afford) any touch with modern medicine. They live inspite of it; and may be happily too. This inverse care law that operates in every other field in our Cartesian thinking should be replaced by an altruistic view. While 10% of the world population enjoys 90% of the wealth, the remaining 90% has to make do with just the paltry 10%! This is the same story in every other field. Let that not be so in scientific medicine, which has to do most good to most people most of the time.





BIBLIOGRAPHY.



01. Arndt KA. Information excess in medicine. Arch. Dermatology 1992; 128: 1249-56

02. Lock S: The future of medical journals. BMJ 1991;303 :1-8

03. Hux JE and Naylor CD. Eye of the beholder. Arch.Inst.Med.1995: 155:2277-80

04. McCormack J. and Greenhalgh T. Seeing what you want to see in research – UKPDS. BMJ2000:320:1720-1722.

05. Editorial. Drug Company Influence on Medical education in USA. Lancet 2000;356:781

06. Itzkovich JS. Doctors going on strike in Israel may be good for health. BMJ2000;320:1561

07. Angell M. Is Academic Medicine for sale? NEJM 2000;342:1516-18

08. Little M. Humane Medicine 2000. Newyork.

09. Harris WS,Gowda M, Kolf JW et.al. Randomised Controlled study of intercessory prayer . Arch. Int. Med. 1999; 159: 2273-2278

10. Strandberg SE, Saloamaa VV, Mankkakarinen et.al. Long Term Mortality after 5 –year multifactorial prevention. JAMA 1991:266:1225-29

11. Dawkins R. The Blind WatchMaker. Book. W.W.Norton & Company, NewYork and London. 1996.

12. Sharma S. Quantum Rope, 1999. New Age International (P) LTD. NewDelhi